The difference in attendance between younger and older age adolescent tobacco users is shown in Additional file 3. Within our cohort 51 participants gave inconsistent answers about their smoking behavior at baseline and follow-up.
Regarding snus use, 53 participants stated at follow-up that they had never used snus, but reported occasional snus use at baseline. In additional analyses where participants with inconsistent answers were removed, the main results were confirmed, but with larger effect size of the transitions of tobacco use. The effect size of the transitions from tobacco use to no tobacco use decreased when removing inconsistent answers data not shown. The prevalence of tobacco use in the study population doubled from adolescents aged 13—15 to those aged 16— All adolescent tobacco use categories had higher prevalence of parental divorce, family smoking and parental alcohol use than adolescent no tobacco users.
Level of educational plans did not differ significantly between adolescent tobacco users and no tobacco users Table 1. Adolescent smokers and dual users, but not snus users, had higher mean levels of neurotic personality traits than non-tobacco users.
All categories of adolescent tobacco users had higher mean levels of extrovert personality traits, while only dual users had higher levels of psychotic personality traits than the non-users of tobacco.
The crude prevalence of ever tobacco use in adolescence and current tobacco use in young adulthood are shown in Fig.
Hence, the probability for young ever tobacco users to quit was about one in three for snus users and smokers, and about one in six for dual users. Among the dual users, however, nearly one third had quit smoking and switched to snus only. Tobacco use as young adults within adolescent tobacco user groups. Study population, unadjusted. For the transition from adolescent smoking to adult snus only use, as well as from dual use to snus only use, small differences were found between age groups.
The dual users were mostly a mix of daily users of one tobacco product and occasional users of the other product, besides a few using either both products occasionally or both products daily. The composition of the dual user group changed from adolescence to adulthood.
In our study population, one third of the initial occasional smokers and snus users had quit all tobacco, while half of them were daily users as adults, regarding current use of tobacco at both time points. Table 3 shows the results from the multivariable regression analyses of associations between ever tobacco use in adolescence, and risk of current or no tobacco use in adulthood.
The RRs with confidence intervals CI of adolescent snus users to be smokers in young adulthood, adjusted for age and family smoking, was 2. The RRs of adolescent smokers and dual users of still being smokers in adulthood, adjusted for age and family smoking, were 2. Adolescent snus users and smokers had a doubled, or more than doubled, likelihood to be smokers as adults.
Adolescent dual users carried more than a threefold risk to be smokers as young adults, but at the same time also a comparable risk to be snus only users.
Adolescent snus users had nearly a threefold risk of still being snus users as young adults, with adjusted RR 2. Adolescent smokers had no significant likelihood of being snus only users as young adults. The likelihood of adolescent boys to become tobacco free in young adulthood, given tobacco use in adolescence, was comparable for previous snus users and smokers with RR 0. The adolescent dual users had clearly the lowest likelihood to become tobacco free in young adulthood Table 3.
Due to the relatively high rates of missing values attached to these variables Additional file 4 , we chose to present the results as sensitivity analyses. These sensitivity analyses gave weaker associations, but no substantial change from the main results in Table 3 : With all confounders included, the risk for adolescent snus users to be current smokers as adults were RR 1.
The corresponding RRs for smokers and dual users to be current smokers at follow-up were 2. The fully adjusted risks of adolescent snus users, smokers and dual users to be current snus users as adults were RR 2. A few comparative results for women belonging to the same cohort are given in Additional file 1.
In this study, adolescent snus only users conferred a doubled risk of smoking, and almost a threefold risk to continue with snus as young adults. Adolescent dual users conferred a threefold risk to still be smokers in adulthood.
The transition from smoking to snus only use was less common. The associations between adolescent snus use and smoking in young adulthood in this study were similar to previous studies [ 27 , 28 , 29 ]. One recent study among young men enrolled in the army in Switzerland did not find any beneficial effect of snus use on smoking, but increased likelihood of smoking initiation and continuation [ 30 ]. In our study, a considerable proportion of the adult dual users used snus daily and smoked occasionally, instead of the opposite constellation, in line with another Norwegian study [ 14 ].
A US review including six studies among both adolescents and adults published since demonstrated the heterogeneity in design across studies, but indicated, similar to our results, limited transition from exclusive smoking to exclusive smokeless tobacco use [ 32 ].
In Sweden, both cigarette starters and snus starters were found, in contrast to our study, to have a low risk to end up as current smokers [ 31 ]. In USA, one study did not find any association between snus debut and later smoking [ 33 ] and another found little evidence of transition from one tobacco product in adolescence to another in adulthood [ 34 ].
Scandinavian studies among adults have supported a possible harm reduction effect of snus; A Swedish study found that men using both cigarettes and snus during their lifetime were likely to quit cigarettes and continue with snus only. The same research group found the availability of snus to contribute to the low Swedish rates of smoking among men [ 12 , 13 ]. Lund et al. The results were not replicated in USA, where transitions between cigarettes and smokeless tobacco was infrequent [ 35 ].
Also, smoking cessation for dual users was not different from that of exclusive smokers, and even when the dual users were more likely to have tried to quit, they were found to relapse more quickly than the smokers [ 36 , 37 ]. In our study, the high rates of dual use with daily snus use and low frequent smoking in adulthood may be seen as a step on the way to exclusive snus use or non-use of tobacco. In line with this, the dual users in our cohort had a high probability to be snus only users in adulthood.
Declining cigarette smoking, but stable rates of overall tobacco use and poly-tobacco use among youth, are reported from USA [ 38 ]. A Norwegian study found a potential for harm reduction with snus, but also a tendency to combine non-daily smoking and snus use [ 14 ]. In our study, the adolescent dual users seem to be clearly more dependent with lower RR of becoming non-users of tobacco in adulthood than the corresponding smokers or snus users. Dual and poly-tobacco use has been associated with high risk adolescents and high levels of nicotine dependency in other countries as well [ 31 , 38 ].
A main impression across studies is that adolescent tobacco users seem to be more likely than adults to progress from snus to smoking. The studies also show that transitions between tobacco products vary between countries and are probably influenced both by their relative availability, the pattern of use in peers, marketing strategies for sale, and by national tobacco policies [ 39 , 40 ].
Snus users and smokers seem to have much of the same susceptibility to tobacco use, according to individual background factors. In this sense, one could speculate if adolescents who use snus might smoke if snus was not available [ 41 ]. Exclusive snus use in adolescence has been associated with psychosocial risk factors similar to smokers, but with healthier behaviour and higher academic orientation compared to smokers and dual users [ 1 ].
Similarly, the risk profile of snus users regarding social factors, lifestyle and health were found to lay between non-users of tobacco and smokers, being less favourable than those of non-users, but more advantageous than those of smokers [ 14 , 18 , 42 ].
Different risk profiles of snus users and smokers points to partly different user groups. In our study, this may explain a higher propensity of adolescent smokers than snus users to be smokers or dual users in young adulthood. Nicotine dependence might explain a common propensity of future smoking as well as snus use. The quantities of delivered nicotine in snus are similar to cigarettes [ 7 ].
Easy access to sufficient amounts of nicotine from snus, as smoking in restaurants and bars was banned in , may have influenced the transition to snus in our cohort period. The use of other tobacco products, as hookah and cigarillos, are almost non-existing in Norway [ 17 ].
Electronic cigarettes with nicotine have not yet entered the market for sale. The large full-scale population with a high participation rate as adolescents gave a representative sample in Young-HUNT1 at baseline.
The broad range of demographic and behavioural measures in Young-HUNT1 allowed thorough examination of risk factors at baseline. Another strength was the long follow-up time and the possibility to examine the transitions into the more established tobacco use in young adulthood. The importance of including former smoking as baseline ovariates when studying predictors of future smoking has been addressed in several studies [ 27 , 33 ].
Sign Up for News Updates. Sign up. Not convinced? Find out more ». Share this article via facebook Share this article via twitter Share this article via messenger Share this with Share this article via email Share this article via flipboard Copy link. Share this article via comment Share this article via facebook Share this article via twitter. More Stories. The relationship of snus use to diabetes and allied conditions. Axell T. A prevalence study of oral mucosal lesions in an adult Swedish population.
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Download references. You can also search for this author in PubMed Google Scholar. EC performed the literature review and interpreted the data. KT and EC created the manuscript. All authors read and approved the final manuscript. Correspondence to Elizabeth Clarke. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Epidemiological studies investigating the association between snus use and lung cancer.
Those epidemiological findings which are statistically significant either protective or causative are highlighted in red. Klimisch Score adapted from Regulatory Toxicology and Pharmacology 25 , [ ]. Epidemiological studies investigating the association between snus use and myocardial infarction. Epidemiological studies investigating the association between snus use and stroke. Epidemiological studies investigating the association between snus use and pancreatic cancer.
Reprints and Permissions. Clarke, E. Snus: a compelling harm reduction alternative to cigarettes. Harm Reduct J 16, 62 Download citation. Received : 17 April Accepted : 06 November Published : 27 November Anyone you share the following link with will be able to read this content:.
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Abstract Snus is an oral smokeless tobacco product which is usually placed behind the upper lip, either in a loose form or in portioned sachets, and is primarily used in Sweden and Norway. Introduction Snus is a moist oral tobacco product which is placed behind the upper lip, either loose or in portioned sachets, which resemble miniature tea bags. Prevalence data Sweden has the longest history of snus use in Europe.
Full size image. Tobacco smoking epidemiology Since the early s, thousands of epidemiological, clinical and scientific publications have reported the adverse health consequences of smoking.
Harm reduction potential of snus Tobacco harm reduction is a strategy intended to reduce the health risks associated with smoking to individuals and the wider society. Evidence for specific disease endpoints The endpoints discussed specifically in this review are lung cancer, cardiovascular disease, pancreatic cancer, diabetes, oral cancer and non-neoplastic oral disease. Other cardiovascular risk factors Several studies have investigated other aspects of cardiovascular disease including hypertension, atherosclerosis and markers for metabolic syndrome such as serum triglycerides.
Diabetes There are eleven primary research publications [ 56 , 58 , 61 , 62 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ], all based in Sweden, which have investigated the potential effects of snus use on type II diabetes or related components of metabolic syndrome such as glucose tolerance or insulin sensitivity.
Oral cancer Mouth cancer, also known as oral cancer, is classified as such when a tumour develops in the lining of the mouth. Non-neoplastic oral disease Non-neoplastic oral disease includes oral mucosal lesions including leukoplakia , periodontal and gingival diseases, tooth loss and dental caries. Oral mucosal lesions Oral mucosal lesions may generally be defined as any abnormal change or swelling on the epithelial lining of the mouth, lips or gums, which do not contain any malignant or pre-malignant cells [ 84 ].
Periodontal and gingival diseases Gum disease is a very common condition where the gums become swollen, sore or infected. Dual use, gateway and cessation The potential effects of snus use when combined with cigarette use dual use , the potential role of snus use to act as a gateway to cigarette use and the role of snus to aid smoking cessation will be discussed in this section of the review.
Dual use There is concern that uptake of secondary snus use among daily smokers may result in permanent dual use and increase the risk of tobacco-related morbidity and mortality above the risk associated with single-product use [ 99 ]. Gateway The gateway hypothesis posits that, among persons who have not previously smoked, users of snus are more likely than non-users to take up smoking. Cessation Seven studies [ , , , , , , ] investigating the effect of snus on smoking cessation were identified in the scientific literature; four were conducted in Scandinavia [ , , , ] and three in non-Scandinavian countries [ , , ].
Conclusion This review found that the health risks associated with snus use, where nicotine is decoupled from harmful tobacco smoke, are considerably lower than those associated with smoking cigarettes. Availability of data and materials Not applicable. References 1. Article Google Scholar 8. Article Google Scholar Google Scholar PubMed Google Scholar The sale of the moist powder tobacco is illegal across the EU — but a recent study found that more people are using snus than cigarettes for their fix of nicotine in Norway, a non-EU member.
During Euro , Vardy claimed he had been given the all-clear to use the nicotine pouches in order to prepare for matches. He was pictured holding a can of Red Bull and a tin of snus during the tournament. Health experts have questioned the cocktail of nicotine and caffeine with both stimulants on the World Anti-Doping Agency monitoring list.
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